Deadly Descent: Beechcraft Breaks Up in Terrifying Incident
47,051
Published 2024-07-03
Tuesday 3 May 2016
Fatalities: 3 / Occupants: 3
The instrument-rated pilot was conducting a personal cross-county flight and was operating on an instrument flight rules flight plan. While he was flying in visual conditions between cloud layers at 7,000 ft and heading toward the destination airport, he reported to air traffic control that the airplane had experienced a vacuum pump failure and that he had lost the associated gyroscopic instruments and part of the instrument panel. The pilot continued toward the destination airport because it had the best weather conditions compared to alternate nearby airports; however, after accepting radar vectors for the GPS approach to the airport, he reported that the airplane had entered instrument meteorological conditions (IMC) and that he had lost a "little bit" of control. He then reported that more of the instruments had failed and that he was trying to get back to 7,000 ft. Shortly after, the controller provided the pilot with the weather conditions at a closer airport and asked him if he would like to try to land there; however, no further communications were received from the pilot. Review of radar data revealed that the airplane made several course and altitude deviations as it proceeded northeast until the end of the data.
The airplane was found separated in multiple pieces along a 0.4-mile-long debris path. Based on the radar data and debris path, it is likely that the pilot experienced spatial disorientation while maneuvering the airplane in IMC without a full instrument panel, that he subsequently lost airplane control, and that the airplane broke up in flight due to overstress during the ensuing uncontrolled descent.
Review of a vacuum pump manufacturer's service letter (SL) revealed that the mandatory replacement time for the make and model vacuum pump was 500 aircraft hours or 6 years from the data of manufacture, whichever came first. Compliance with the SL was not mandatory for 14 Code of Federal Regulations Part 91 operations. The vacuum pump was manufactured in May 1999, which was 17 years before the accident. Additionally, the airplane was not equipped with a backup/standby vacuum pump.
Metallurgical examination of the vacuum pump revealed that the rotor had separated radially in numerous locations. Three vanes remained intact, and three vanes separated into numerous pieces. Rotational scoring/rubbing marks were observed on the rotor and pump housing.
Additionally, debris was noted in the inlet screen, but the engine had impacted a dirt field. It is likely the rotor's contact with the pump housing caused the failure of the pump rotor and vanes; however, it could not be ruled out that debris ingestion contributed to their failure.
The pilot had severe coronary artery disease, and toxicological testing revealed low levels of diphenhydramine, a sedating antihistamine allergy treatment and sleep aid, and zolpidem, a prescription sleep aid. However, there was no evidence that the pilot's heart disease or sedating medications impaired his performance or incapacitated him.
Probable Cause: The pilot's loss of airplane control while operating in instrument meteorological conditions with only a partial instrument panel due to a failure of the airplane's vacuum pump.
Contributing to the accident were the pilot's spatial disorientation and the operation of the vacuum pump beyond the 6-year time limit recommended by the vacuum pump manufacturer.
• Deadly Descent: Beechcraft Breaks Up ...
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All Comments (21)
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Based on the radar data and debris path, it is likely that the pilot experienced spatial disorientation while maneuvering the airplane in IMC without a full instrument panel, that he subsequently lost airplane control, and that the airplane broke up in flight due to overstress during the ensuing uncontrolled descent. Please check the Description for full information
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Why oh why do people do this?? "I have an emergency, but I'd like to press on for hundreds of more miles, rather than landing at the nearest available to sort things out" A vacuum issue and partial panel is not going to get better, it can easily get worse (and it did), the weather can change (and it did), and the longer you're in the air the less options you have. Land while you have VMC and at least a partial panel.
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Go offshore, descend into the clear, land the pane in VFR
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A 180 degree turn to remain VFR on top till VFR conditions could be found might have been better than continuing toward the destination. Very difficult “nightmare “ situation! R.I.P.
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The Bonanza is such a nice aircraft, but I wouldn't fly IFR without at least a backup artificial horizon. Better yet, rip out the 1950's technology vacuum system and pop a couple of G5s in there with battery backup. That pilot knew all too well what kind of trouble he was in when the vacuum system quit. Nightmare situation. RIP.
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Yeah that controller had no idea what partial panel was, so that "emergency" meant nothing to him. The pilot must take initiative, there's no other way to do it.
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No Gyro means land at the nearest suitable airport and not all the way to your original destination..
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Dry vacuum pumps fail. Oil vacuum pumps better but they were messy. A couple of things to help staying alive are proficiency and redundancy. RIP. Hopefully this accident prevents another.
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A Bonanza is a very clean airplane, and picks up speed very fast. This scenario isn't unusual for a Bonanza with a pilot that isn't proficient at IFR. I was almost killed a long time ago with the same scenario in a Bonanza with an IFR rated pilot that hadn't flown any actual IFR in almost a year. Lesson learned. Sad.
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2.5 hours of fuel. Was the weather overcast in every direction for 2 hours of flight time?
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turn around to airport you came from.
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I felt bad when he said he hoped for clearer skies. He told the controller he didn't want to go back IMC but they didn't know what vaccum system failure meant, so they didn't pick up on the danger he was in when he reported going back into IMC. Once he went back into the clouds they were dead. He ripped that Bonanza into pieces. I didn't expect to see what I did in the docket photos back when I first watched this accident on ASI. He was out of imc but the new controller put him back in it thinking vaccum system loss wasnt a big deal.
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a vacuum pump is mounted on the engine to provide suction to twirl the vaned gyro rotors inside the flight instruments. practicing for partial panel failure is tedious and not necessarily a guarantee to a successful outcome in this kind of emergency. those who choose to fly in instrument conditions in single engine aircraft should invest in back-up electric gyro instruments or other redundancy options.
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Seems like there was a coastal wx system but what about to the west and south?
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If the pilot couldn’t handle emergencies like this in IFR conditions he shouldn’t be flying in them. Complacency and lack of proficiency has no place in aviation, unless you want to die. Knowing your limitations and using good judgment is a must for longevity of life.
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In training instruments would be covered to simulate failure. I found it was best for me to cover them when they actually failed to keep my mind from distractions and confusion.
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"Partial or vacuum system lost, thank you" the ATC probably didn't know what it meant, say you have no horizon or whatever the problem is, and clarify what it means in reality like "unable IMC". In this case the second horizon probably died just before the crash (just assuming they had a backup when flying IMC)..
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Don't know if his heading indicator was functioning or not, but an increase in heading numbers indicates a right turn, decreasing a left. Dropping 10 flaps and the gear will slow the plane during descents, giving more time to react. I've flown under the hood using turn and bank indicator and heading only and it worked out okay. Trim for best glide and a gentle 500fpm descent and don't look out the windscreen! Poor guy must've been terrified. Did he not check weather at his destination and route? All it takes is a quick call to the ASOS.
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Declared an emergency and keeps flying to his designation? Dumb. Land at closest VFR airport immediately! Everything going wrong from his first call. Get down fast.
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Steam gauges are great, but always have electronic gauges too. Horizon, VSI, speed altitude, everything is available electronic... requesting a radar approach was smart... don't know why they didn't give it to them
